Provider Demographics
NPI:1720859556
Name:LASSALLE, CARLA VICTORIA
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:VICTORIA
Last Name:LASSALLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1631 CALLE SANTA EDUVIGIS # 1631
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-4228
Mailing Address - Country:US
Mailing Address - Phone:939-437-0717
Mailing Address - Fax:
Practice Address - Street 1:1631 CALLE SANTA EDUVIGIS # 1631
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00926-4228
Practice Address - Country:US
Practice Address - Phone:939-437-0717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR7810103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily